Journal of Plastic, Reconstructive & Aesthetic Surgery (2013) 66, 1263e1270

Fingertip reconstruction using thehypothenar perforator free flap

Kwang Seog Kim*, Eui Sik Kim, Jae Ha Hwang, Sam Yong Lee

Department of Plastic and Reconstructive Surgery, Chonnam National University Medical School,Gwangju, Korea

Received 10 December 2012; accepted 1 May 2013

KEYWORDSFingertip;Hypothenar;Perforator;Flap

* Corresponding author. Departmentive Surgery, Chonnam National UnJebong-ro, Dong-gu, Gwangju 501-756363, þ82 62 220 6352; fax: þ82 62 2

E-mail address: pskim@chonnam.a

1748-6815/$-seefrontmatterª2013Brihttp://dx.doi.org/10.1016/j.bjps.2013.0

Summary Background: The purpose of this study was to present the results of using thehypothenar perforator free flap for fingertip reconstruction.Methods: Between 2004 and 2012, 24 patients underwent reconstruction of fingertip defectsusing the hypothenar perforator free flap at our institute.Results: Flap survival was complete in 22 flaps. Flap size ranged from 1.5 to 2.5 cm in widthand 2.7e4.5 cm in length. Donor sites were closed primarily in all patients. Healing of all donorsites was uncomplicated, and donor-site morbidity was minimal with acceptable scarring.Long-term follow-up for more than 12 months (range, 12e51 months) was possible in 14patients and revealed excellent flap sensibility.Conclusions: The hypothenar perforator free flap provides acceptable functional and cosmeticoutcomes for the reconstruction of fingertip defects. The authors recommend that this flapshould be considered as a useful option for fingertip reconstruction.ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Injuries to the palmar aspect of the fingertip are among themore commonly encountered hand injuries, and variousreconstruction methods have been developed. However,the reconstruction of fingertip injuries for acceptablefunctional and cosmetic outcomes remains a challenge for

t of Plastic and Reconstruc-iversity Medical School, 427, Korea. Tel.: þ82 62 22027 1639.c.kr (K.S. Kim).

tishAssociationofPlastic,Reconstruc5.006

reconstructive surgeons because of the limited availabilityof local soft tissue.

The palmar skin of the fingertip has specific anatomicalcharacteristics and highly sophisticated functions. There-fore, whenever possible, palmar defects of the fingertipshould be reconstructed using palmar skin that has char-acteristics similar to those of the fingertip. However,because there is a possibility of postoperative scarcontracture on the flap donor site, palmar skin flaps havebeen less commonly used than other skin flaps.1e4 Toresolve this problem, the hypothenar area can be consid-ered as an alternative flap donor site because of itsrelatively abundant skin for flap harvesting.

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Figure 1 Cutaneous territories in the hypothenar eminenceaccording to the type of artery supplying each territory. PU,proximal ulnar area supplied by musculocutaneous perforators(mostly branching off from the proximal deep branch of theulnar artery); DU, distal ulnar area supplied by fasciocutaneousperforators (branching off from the ulnar palmar digital arteryof the little finger); R, radial area supplied by small perforators(arising primarily from the superficial palmar arch) throughthe palmar aponeurosis; O, overlapping areas between thevascular territories.

1264 K.S. Kim et al.

Perforator flaps have many unique advantages, includingless donor-site morbidity and better accuracy in recon-struction. Therefore, the concept of the perforator flap hasalso been applied to develop several perforator flaps in thehand.1e8 Cadaver studies have shown that some perforatorflaps can be raised from the hypothenar area.5,8 However,in several clinical studies, only the hypothenar perforatorflap harvested from the distal ulnar aspect of the hypoth-enar eminence has been used as a distally based island flapfor the reconstruction of palmar defects around the littlefinger.6,9,10 Furthermore, a survey of the English languageliterature showed no reports of the use of the hypothenarperforator free flap.

The purpose of this study was to present the authors’experiences using the hypothenar perforator free flap forfingertip reconstruction.

Anatomy

The hypothenar eminence comprises the three muscles ofthe palm that control the motion of the little finger: theabductor digiti minimi, flexor digiti minimi brevis andopponens digiti minimi muscles. The hypothenar eminencecan be divided into three territories according to the typeof artery supplying each territory (Figure 1).5 However,there are partial overlaps among the vascular territories onthe hypothenar eminence.

Although the number of perforators noted in anatomicstudies varies between 1 and 10, perforators constantly existin the hypothenar eminence.5,8,11 There are three types ofvenous drainage in the hypothenar eminence: (1) drainageinto the superficial palmar veins that connect with the su-perficial veins of the forearm; (2) drainage through thevenae comitantes of the ulnar proximal digital artery of thelittle finger and the proximal deep branch of the ulnar ar-tery, which continue to the venae comitantes of the ulnarartery; and (3) drainage into the dorsal metacarpal veins,which drain into the basilic veins of the forearm.5 Sensoryinnervation of the palmar hypothenar eminence is by thepalmar cutaneous branch of the ulnar nerve; sensory inner-vation of the dorsal hypothenar eminence is by the dorsalbranch of the ulnar nerve.5 Therefore, a neurosensateperforator flap can be raised from the hypothenar eminence,and this flap can be used as an island flap or a free flap.

Patients and methods

Between 2004 and 2012, 24 patients (14 men and 10women) underwent reconstruction of fingertip defectsusing the hypothenar perforator free flap.

Subjective opinions of the surgical results were obtainedfrom the patients at follow-up visits. An author (K.S.K.) andan independent surgeon evaluated the surgical results byperforming physical examinations and assessing photo-graphs throughout the follow-up period. Their opinion ofthe overall surgical results, which included flap contour,durability, elasticity, skin colour and texture, scar severity,pain, hypersensitivity, cold intolerance and sensibility, wascategorised as poor, fair, good or excellent. Objectiveassessment of sensory recovery was conducted bycomparing the difference between the static two-point

discrimination of the flap and the uninjured contralateralfingertip, and statistical analysis was performed using STATAversion 11.0 (StataCorp, College Station, TX, USA). Whenjudgements differed, the poorer results were accepted.

Operative technique

Before the operation, the location of the hypothenar per-forators that would serve as the flap pedicle was determinedusing Doppler ultrasound. Under general anaesthesia orbrachial plexus block, the patient was placed in a supineposition. The operation was performed under pneumatic

Hypothenar perforator free flap 1265

tourniquet control without limb exsanguination and undermicroscopic magnification to permit better identification ofthe cutaneous vessels. After the devitalised tissue in thefingertip wound was debrided, the recipient vessels wereprepared in the defect. Depending on the size, shape andcondition of the resulting defect, a perforator free flap wasdrawn on the hypothenar eminence. The ulnar or radialborder of the designed flap was first incised through the skinand subcutaneous tissue, and the available perforatorsemerging from the hypothenar muscles were identified usingthe suprafascial dissection technique. The remaining borderof the flap was incised, and retrograde intramusculardissection of the confirmed perforators was conducted tothe underlying muscle or fascia where the pedicle arose.After the flap was skeletonised by severing unwanted per-forators, the flap was completely elevated from the under-lying muscle or fascia. The viability of the flap was checked,and the flap pedicle was cut without damage to the mainvessels. The raised flap was placed on the fingertip, and theflap pedicle was anastomosed in an end-to-end fashion tothe recipient vessels. The flap margin was sutured to thedefect margin, and when complete primary closure of thedefect was impossible because of the bulkiness of the flap,the remaining raw surface of the flap was covered with asplit-thickness skin graft from the hypothenar area close tothe flap donor site. The donor site was closed primarily.

Postoperative care

Postoperatively, the patients received daily 5000 IU ofheparin by continuous intravenous drip for 7 days, lowermolecular weight dextran 500 cc by continuous intravenousdrip for 5 days, lipo-prostaglandin E1 (alprostadil-lipo) 10㎍by continuous intravenous drip for 7 days and aspirin 300 mgorally for 14 days. Postoperative monitoring was performedusing clinical examinations. Doppler examinations were notperformed because the flaps were very small and clinicalsigns provided enough evidence of flap survival after suc-cessful vessel anastomosis. The hands were elevated tominimise postoperative swelling, and the operated fingerswere immobilised for <2 weeks. All patients were encour-aged to apply a silicone gel sheet and a garment on thedonor site for at least 6 months.

Results

The age of the patients ranged from 28 to 71 years (mean,48.2 years), and postoperative follow-up ranged from 6 to 51months (mean, 16.6 months). All patients were right-handedand had wounds resulting from traumatic injuries (Table 1).

Of 24 flaps, all flaps were harvested from the ipsilateralhand, 13 from the proximal ulnar aspect of the hypothenareminence, seven from the distal ulnar aspect of thehypothenar eminence and four from two or more areas ofthe proximal ulnar, distal ulnar and radial areas flaps(Figures 2 and 3). Flap survival was complete in 22 cases.The causes of the two flap failures were the use of a lessreliable perforator with weak visible pulsation and pediclecompression by the flap in one patient and postoperativeaccidental blunt trauma during sleep in one patient. Thesepatients were treated with a thenar flap and a cross finger

flap, respectively. Flap size ranged from 1.5 to 2.5 cm inwidth and from 2.7 to 4.5 cm in length. In 17 patients, oneartery and one vein (vena comitans or superficial vein)were anastomosed with the recipient artery and vein, andin two of those 17 patients, a superficial vein was usedbecause of short length of the vena comitans. In sevenpatients, one artery and two veins (one vena comitans andone superficial vein) were anastomosed with the recipientartery and veins. The perforators used had an averagediameter of 0.4 mm and were anastomosed using an 11/0 or a 12/0 suture. Nerve coaptation was not performed inany patient. To relieve mild and temporary venouscongestion of the flap, bloodletting or medicinal leecheswere intermittently used for 3 days in four patients. A split-thickness skin graft <3 cm2 in size was applied to the rawsurface (sidewall) of the flap to avoid pedicle compressionby tight closure of the bulky flap in six patients. Of the sixpatients, a debulking procedure (secondary excision) wasperformed in three, but any additional procedure was notneeded in the other patients because the amount of theskin graft was minimal and the dimension of the graftsreduced as the swelling of the flap subsided. Donor siteswere closed primarily in all patients, and healing of alldonor sites was uncomplicated.

In the 22 successfully reconstructed fingertips, flapcontour, durability, elasticity, skin colour and skin texturewere satisfactory, and donor-site morbidity was minimal,with acceptable scarring at the final follow-up visit. Nopatient experienced postoperative hypersensitivity or coldintolerance in the reconstructed fingertip, and all patientswere completely satisfied with the results. Outcomes wereassessed by the author and the independent surgeon as‘good’ in three patients and ‘excellent’ in the other 19patients. Follow-up for >6 months and <12 months (range,6e10 months) was possible in eight patients. The meanstatic two-point discrimination was 5.0 mm of these eightreconstructed fingertips (range, 2e8 mm) and 3.1 mm(range, 2e6 mm) for the contralateral fingertips. The dif-ference was statistically significant (p Z 0.0156, sign test).Long-term follow-up for more than 12 months (range, 12e51months) was possible in 14 patients. The mean static two-point discrimination of these 14 reconstructed fingertipswas 4.0 mm (range, 2e6 mm), similar to the 3.7 mm (range,2e5 mm) for the contralateral fingertips. The differencewas not statistically significant (p Z 0.125, sign test).

Discussion

Types of the hypothenar perforator flap

The following four types of hypothenar perforator flaps aretheoretically possible.

(1) Proximal ulnar hypothenar perforator flap: This is theflap from the proximal ulnar aspect of the hypothenareminence based on perforators emerging from thehypothenar muscles, which mostly branch off from theproximal deep branch of the ulnar artery. The skin ofthe proximal ulnar aspect of the hypothenar eminenceis thicker than that of the distal aspect; therefore, theproximal ulnar hypothenar perforator flap should be

Table 1 Patient Summary.

Patient Age(yr)

Sex Occupation Type of injury Injured fingerand site

Flap Timing of surgery(days after injury)

S2PD (mm) Follow-upperiod (mo)

Cx

Size (cm) Main donorsite

Donor siteclosure

Flapsite

Contralateralfingertip

1a 52 M Indoor labourer Pulp avulsion Rt thumb, RU 2.0 � 4.0 DU PC D (20) 6 3 82a 60 F Housewife Pulp avulsion Rt ring, UD 1.5 � 3.0 PU PC D (28) 3 3 213 42 M Indoor labourer Pulp avulsion Lt ring, RU 1.8 � 2.7 PU PC E 3 3 154 58 F Farmer Pulp avulsion Lt ring, RU 2.0 � 3.0 PU, R PC E 4 4 515 28 M Indoor labourer Pulp and palmar

skin defectRt index, RU 1.5 � 4.5 PU, DU, R PC D (21) 2 2 48

6 47 F Housewife Fingertipamputation

Rt middle, RD 1.8 � 3.0 PU PC D (10) 6 3 6

7 66 M Indoor labourer Fingertipamputation

Rt index, RU 1.4 � 3.0 PU PC A (3) e e e Flapfailure

8 48 F Housewife Fingertipamputation

Rt middle, RU 2.5 � 3.0 PU, DU PC D (12) e e e Flapfailure

9 71 M Farmer Pulp avulsion Lt ring, UD 1.6 � 3.0 DU PC E 6 5 1210 35 M Office worker Pulp avulsion Rt thumb, RU 2.0 � 4.0 DU PC A (3) 6 3 711 62 F Housewife Fingertip

amputationRt middle, RU 2.0 � 3.0 PU, R PC A (4) 5 5 23

12 47 F Indoor labourer Fingertipamputation

Rt thumb, RD 1.8 � 3.2 DU PC D (10) 2 2 9

13 45 M Indoor labourer Pulp avulsion Lt middle, UD 2.0 � 3.0 PU PC E 4 4 1714 48 M Outdoor labourer Pulp avulsion Lt ring, RD 1.8 � 3.0 PU PC E 5 4 1215 53 M Office worker Fingertip

amputationLt index, RD 1.7 � 2.7 PU PC E 4 3 18

16 29 F Office worker Pulp avulsion Rt index, RU 1.8 � 3.0 PU PC E 4 2 917 56 M Outdoor labourer Pulp avulsion Lt middle, RD 2.0 � 3.0 DU PC D (14) 4 4 2218 47 F Indoor labourer Pulp avulsion Lt ring, RU 1.5 � 3.0 PU PC E 4 3 1019 59 M Outdoor labourer Fingertip

amputationRt ring, RU 1.5 � 3.0 DU PC A (4) 8 6 10

20 63 M Farmer Pulp avulsion Rt ring, RU 1.8 � 2.7 PU PC E 5 5 1421 42 F Housewife Pulp avulsion Rt middle, RD 1.8 � 3.0 PU PC D (10) 4 4 1622 37 F Office worker Pulp avulsion Rt ring, RU 1.8 � 2.7 PU PC D (17) 4 3 823 28 M Indoor labourer Fingertip amputation Lt index, RU 2.0 � 3.0 DU PC A (4) 3 3 1724 34 M Indoor labourer Fingertip amputation Lt middle, RU 2.0 � 3.0 PU PC E 4 3 13Mean 48.2 1.8 � 3.1 4.4 3.5 16.6

S2PD, static two-point discrimination; Cx, complication; M, male; F, female; Lt, left; Rt, right; RD, radial dominance; RU radial and ulnar; UD, ulnar dominance; PU, proximal ulnar areasupplied by musculocutaneous perforators; DU, distal ulnar area supplied by fasciocutaneous perforators; R, radial area supplied by perforators through palmar aponeurosis; MA, multipleareas over 2 of the proximal ulnar, distal ulnar, and radial areas; PC, primary closure; E, emergency stage; A, acute stage; D, delayed stage.a Cases presented in the article.

1266K.S.

Kim

etal.

Figure 2 A 52-year-old man with an avulsion injury to the pulp of the right thumb. (A) Preoperative appearance. A 2.0 � 4.0-cmhypothenar perforator free flap was designed on the distal ulnar aspect of the right hypothenar eminence to cover the defect.(B) Appearance at 8 months after surgery. The postoperative course was uneventful, and the long-term result was satisfactory.

Hypothenar perforator free flap 1267

raised in a suprafascial manner to make a thin flap.There is debate about whether the flap provides sen-sibility.5,8 However, we have often found cutaneousnerve branches in this area. Although primary closure ofthe flap donor site is easier in the proximal than in thedistal ulnar hypothenar region, there is a possibility ofleaving a contour deformity of the hypothenareminence after primary closure of a wide donor-sitedefect in the proximal ulnar hypothenar region.

(2) Distal ulnar hypothenar perforator flap: This is the flapfrom the distal ulnar aspect of the hypothenareminence, based on the fasciocutaneous perforatorsbranching off from the ulnar palmar digital artery ofthe little finger. The distal ulnar aspect of the hypoth-enar eminence has a thin and durable fasciocutaneouscomponent. This area has a constant vascular andneural supply from the ulnar palmar digital artery ofthe little finger and the dorsal or the palmar cutaneousbranch of the ulnar nerve.5 Therefore, this flap hasbeen used primarily as a distally based island flap forreconstructing palmar defects around the little finger.The ulnar palmar digital artery of the little fingercommunicates with the radial palmar digital arterynear the proximal interphalangeal joint; therefore, theflap can reach the little fingertip through pedicledissection in a distal direction.5,6,9,10 In addition, theflap can be used to reconstruct the ring and middlefingers and the ulnar side of the palm.12 However, thehypothenar perforator flap must be used as a free flapfor the reconstruction of other areas. Although there isless skin in the distal region than in the proximal region,the flap donor site can be closed primarily if the widthof the flap is <2 cm because of the elasticity of thedorsal skin of the hand. However, there is a possibility

of web space distraction after primary closure of a widedonor-site defect.

(3) Radial hypothenar perforator flap: This is the flap fromthe radial border of the hypothenar eminence, basedon perforators arising primarily from the superficialpalmar arch through the palmar aponeurosis. The flapdonor site is easy to close primarily and does not leave ascar on the ulnar border of the hand, which is the maincontact area of the hand. However, the perforators aresmaller in this area than in other areas.

(4) Combined hypothenar perforator flap: This is the flapwhich comprises the skin areas of two or more of theabove three flaps. This flap may be useful for coverageof large defects that cannot be covered using the otherflaps. However, multiple perforators must usually beincluded in the flap, or augmentation of the vascularpedicle may be necessary, because of the size limita-tion of the perforasome. We experienced partial flapnecrosis in the reconstruction of a little finger using a2.0 � 7.0-cm hypothenar perforator island flap basedon a reliable distal perforator.

Criteria to choose the one of types of thehypothenar perforator flap

Selection of types of the flap is based mainly on preoper-ative Doppler examination and condition of the donor siteincluding previous scar and callus. However, as mentionedabove, each type of the hypothenar perforator flap has itsown features. Therefore, the features of types of thehypothenar perforator flap, and the size, shape and con-dition of the resulting defect should be considered asimportant factors to choose the one of types of the

Figure 3 A 60-year-old woman with an avulsion injury to the pulp of the right ring finger. (A) Preoperative appearance. A1.5 � 3.0-cm hypothenar perforator free flap was designed on the proximal ulnar aspect of the right hypothenar eminence to coverthe defect. (B) Intraoperative view showing the elevated flap. (C and D) Appearance at 21 months after surgery. The long-termresult was satisfactory, and the static 2-point discrimination was 3 mm for both the resurfaced and uninjured ring fingertips.The donor site scar was aesthetically acceptable.

1268 K.S. Kim et al.

hypothenar perforator flap. In this study, the proximal ulnarhypothenar perforator flap was primarily considered toclose the donor site easily, the distal ulnar hypothenarperforator flap to harvest a thin flap and the combined

hypothenar perforator flap to harvest a larger flap or toavoid a scar on the ulnar border of the hand. The radialhypothenar perforator flap was not used because the per-forators and the flap dimension are smaller.

Hypothenar perforator free flap 1269

Advantages and disadvantages of the hypothenarperforator free flap in fingertip reconstruction

The hypothenar perforator free flap has many advantagesin reconstructing fingertip defects, including being a one-stage procedure performed in a single operative field,excellent colour and texture match and functional andaesthetic preservation of the fingertip. Although the flap isnot used as a neurosensate flap, long-term follow-up hasshown excellent sensory recovery (Table 1), which weattribute to peripheral nerve ingrowth from the remainingdigital nerves into the transferred flap. The excellent sen-sibility of the flap may be a result of the similar skin texturewith many myelinated fibres and a greater density of nerveendings in the recipient bed.3

Disadvantages include tedious pedicle dissection andmicroanastomosis-related problems. Bulkiness of the flap isanother disadvantage that sometimes requires skin graftingon the raw surface (sidewall) of the flap to avoid pediclecompression by tight wound closure and a debulking pro-cedure that negates the advantage of the flap surgery beinga one-stage procedure. As in the other perforator flaps,temporary venous congestion of the flap may develop in theearly postoperative stage, which requires bloodletting orthe use of medicinal leeches for several days. There is apotential risk of disrupting the arterial supply to the littlefinger after harvesting a flap with a vascular pedicle. Thus,a preoperative digital Allen test and Doppler examinationof the palmar digital arteries are indispensable.6,10 To avoidthis risk, if possible, we harvested the flap without sacri-ficing the main vessels, and the flap was anastomosed in aperforator-to-perforator manner using a supermicrosurgerytechnique.

Inclusion of available superficial veins in the flap

The hypothenar perforator free flap can be safely raisedbecause some reliable perforators with a large diameterand visible pulsation are usually present under the skin ofthe hypothenar area. However, when no reliable perforatoris available in this area, the operative plan must be modi-fied. In this situation, a venous free flap from the sameoperative area can be a unique back-up option.13 Althoughthe popularity of venous free flaps has been limitedbecause of concerns about poor peripheral perfusion andsevere congestion, a venous free flap from the hypothenararea can offer advantages similar to those of the hypoth-enar perforator free flap. In addition, this flap can be madethinner than the hypothenar perforator free flap; hence, itcan provide greater accuracy during fingertip reconstruc-tion. Therefore, when the hypothenar perforator free flapis raised, available subcutaneous veins should be includedin the flap to relieve potential venous congestion andmaintain a potential back-up option.

Hypothenar perforator free flap as an option forfingertip reconstruction

Various flaps including local, regional, distant and free flapshave been used to reconstruct fingertip defects. Of theseflaps, there are much easier and potentially safer flaps than

the hypothenar perforator free flap. However, they are notalways available and each of them has its own advantagesand disadvantages in specific situations. Therefore, the useof the hypothenar perforator free flap can enhance thearmamentarium of methods available to achieve fingertipreconstruction although the flap is a sophisticated alter-native. Actually, we consider the hypothenar perforatorfree flap as a secondary choice for reconstructing fingertipdefects.

Conclusions

The hypothenar perforator free flap provides acceptablefunctional and cosmetic outcomes for the reconstruction offingertip defects. The authors recommend that this flapshould be considered as a useful option for fingertipreconstruction.

Ethical disclosure

This procedure is in accordance with the ethical standardsof our committee on human experimentation and with theprinciples outlined in the Declaration of Helsinki.

Conflict of interest

None.

Funding

None.

References

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